Disease Description (Causes and Symptoms)
Multiple myeloma is a blood cancer in which plasma cells abnormally proliferate in the bone marrow, producing excessive amounts of monoclonal immunoglobulins (or light chains) and affecting the bone marrow, bones, kidneys, and hematologic system. Its major pathophysiological mechanisms include bone destruction (increased bone resorption), anemia and thrombocytopenia caused by infiltration of the bone marrow space, kidney damage caused by monoclonal proteins, and impaired immune function.
Main symptoms
- Bone pain (spine, ribs, pelvis, etc.), pathological fractures
- Fatigue and malaise (anemia)
- Recurrent infections (immunosuppression)
- Worsening kidney function, polyuria, edema, and abnormal urinalysis findings
- Fatigue, nausea, constipation, and mental status changes caused by hypercalcemia
- Bleeding tendency (thrombocytopenia)
Tests used for diagnosis: blood tests (SPEP/IFE, serum free light chains (sFLC)), urine electrophoresis/immunofixation, bone marrow aspiration and biopsy (to determine the plasma cell proportion), and imaging tests (skeletal radiography, CT, MRI, PET-CT).
Treatment Methods
Standard treatment principles: Treatment is individualized according to the patient’s age, overall condition, and disease risk (ISS/R-ISS, cytogenetics).
Drug treatment
- Initial induction therapy (combination therapy): combination of 2–3 drugs, including bortezomib (a proteasome inhibitor), lenalidomide (an immunomodulatory drug), and dexamethasone (a corticosteroid)
- Other drugs: carfilzomib, pomalidomide, cyclophosphamide, and antibody therapies (including daratumumab)
- Targeted and cellular therapies: Treatment options such as CAR-T (e.g., BCMA-targeted therapy) and antibody-drug conjugates (ADCs) have recently been introduced
High-dose therapy and transplantation
- Autologous stem cell transplantation (ASCT): Performed after induction therapy in eligible patients to induce complete remission and prolong survival
- Allogeneic transplantation: Considered in some selected cases
Local treatment and supportive care
- Radiation therapy: Relief of localized pain, treatment of spinal cord compression, or treatment of solitary plasmacytoma
- Treatment of bone lesions: Bisphosphonates (e.g., zoledronic acid), or denosumab in patients with kidney impairment — prevention of bone pain, fractures, and hypercalcemia, and pain relief
- Transfusions, growth factors, antibiotics/prophylactic anti-infective therapy, dialysis (in cases of kidney failure), etc.
Monitoring
- Blood tests (blood cell counts, calcium, creatinine), follow-up of protein electrophoresis/free light chains, and follow-up skeletal imaging
Precautions (during and after treatment)
- Side effects of anticancer drugs: Increased risk of infection, mucositis, nausea/vomiting, diarrhea/constipation, hair loss, bone marrow suppression (anemia/bleeding), and nephrotoxicity (depending on the drug)
- Increased risk of venous thromboembolism (VTE) when using immunomodulatory drugs: Anticoagulant prophylaxis when necessary
- Dental examination is recommended before using bisphosphonates/denosumab (risk of osteonecrosis)
- Vaccines: Inactivated vaccines are recommended; live vaccines may be contraindicated during treatment
Checklist Before an Outpatient Visit (Including Example Questions)
Items/documents to prepare and bring
- A list of all medications currently being taken (including prescription drugs, nonprescription drugs, and supplements)
- Medical history (especially kidney disease, fractures, transfusions, and previous anticancer treatment), and history of surgery and dental treatment
- Copies of recent test results (blood tests, urine tests, bone marrow test results, and imaging tests)
- Symptom diary: location and intensity of pain (pain score), degree of fatigue, episodes of fever or infection, changes in urination or edema, etc.
- Recent weight changes and eating/bowel movement patterns
Example questions for an outpatient visit (for preparation)
- What do my recent test results mean?
- What are the indications for autologous stem cell transplantation, and what does the preparation process involve?
- Which medications do you recommend for managing bone lesions? When should I have a dental examination?
- What vaccines or precautions are needed to prevent infection?
Examples of General Questions to Ask the Doctor
- Is the goal of this treatment to induce remission, relieve symptoms, or prolong survival?
- Am I a candidate for autologous transplantation? What are the risks and expected benefits of transplantation?
- What are the major side effects of the medications that will be used, and how can they be managed?
- Are anticoagulants (for thrombosis prevention) or prophylactic antibiotics necessary?
- What activities should I avoid in daily life (exercise, alcohol consumption, dental treatment, etc.)?
- How do you assess the prognosis (medium- and long-term survival rates)?
Examples of Disease-Specific Questions
- If cytogenetic abnormalities identified in my bone marrow examination (e.g., del(17p), t(4;14), etc.) are present, how will they affect the treatment plan and prognosis?
- Considering the status of my kidney function (creatinine and urinalysis), which is more appropriate, bisphosphonates or denosumab? What are the management guidelines before and after dental procedures?
(Preparing recent test results and a list of current medications along with this material before the appointment can make the consultation more efficient.)